Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 't (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address !` of 3 nv$N. ,t4 �� h � City QA ,-1 _ Lot Size PM <br /> Owner's Name A4 r W..#/�'C _ Address �L' Phone <br /> Contractor Address ��� I _ License No.pS; � Phone ! <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR Ci OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL _,�THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial i= Open Bottom L Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private G Gravel Pack D Tracy Type of Casing Specifications <br /> C Public :3 Other :1 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _-4pprox. Depth ❑ Eastern Surface Seal Installed by _ <br /> Repair Work Done D Type of Pump H,P. State Work Done 6 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _— N <br /> Depth Filler Material{Below 50') W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITIONI% DESTRUCTION Cf lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence.Commercial_ Other <br /> Number of Jiving units: Number of bedrooms 1 'y <br /> Character of soil to a depth of 3 feet: �7 Water table depth Q <br /> SEPTIC TANK `Q Type/Mfg Y. � w Capacity�4e o No. Compartments <br /> PKG. TREATMENT PLT. Df� :;?,o <br /> Method of Disposal' <br /> Distance to nearest: Well�— Foundation� Property Line <br /> LEACHING LINE 17 No. &Length of lines Total length size <br /> FILTER BED D Distance to nearest: Well Foundation Property Lf'ine 0 <br /> SEEPAGE PITS D Depth Size __ Number - - - <br /> SUMPS _7 Distance to nearest: ,Well Foundation Property Line <br /> DISPOSAL PONDS D r <br /> I hereby certify that I have prepared this application and that the'work will be done in accordlnce with San Joaquin cGunp ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. a <br /> Homeowner or licensed agent's signature certifies the follo g-%`I^certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject tdworkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following;"I certify that in the performance of the work fog which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Callfomia." t ' <br /> The applicant must call for e u d inspectlons7aComplete drawing on reverse side. <br /> Signed ��� Title: Date: <br /> F <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by Rata._ Area ` <br /> Pit or Grout Inspection by Date _ Fi Inspection by / r f� ia�ils+.i Date g`•� <br /> Additional Comments: ' sl /`+`� � le, 4V. <br /> D Stk 466-6781 C Lodi 369-3621 L Manteca 873-7104 1-1 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201: <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CAH RECEIVED BY DATE'\ PERMIT NO. » <br /> EH1}24(REV.7!95; � <br /> EH 1426 r �� r 5-1,4� <br /> f <br />